=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104334812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DORISLEYDI GONZALEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2018
-----------------------------------------------------
Last Update Date | 01/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7050 W FLAGLER ST APT 20
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-490-7232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7050 W FLAGLER ST APT 20
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-490-7232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | 5011914
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------